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Preparing for Health Insurance Exchanges

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Development of state-level health care exchanges, as required by federal health care legislation, will include issues and considerations important to audiologists and speech-language pathologists.

The 2010 Patient Protection and Affordable Care Act (ACA) included this mandate to make health care coverage available to the estimated 24 million Americans who do not have employer-sponsored health insurance or are ineligible for established programs such as Medicare or Medicaid. The number includes individuals who are either self-employed or who may work for small employers that do not provide health insurance.

The ACA calls for each state to build and operate a health insurance exchange for its residents. The ultimate goals are not only to expand coverage to more Americans, but also to reduce insurance costs, improve the quality of coverage, and possibly even improve health care itself.

As conceived under the law, an exchange is an organized marketplace for the purchase of health insurance. It may be online, accessible by phone, or a physical site where citizens can compare health insurance plans, enroll in a plan, find out about available subsidies, and obtain customer support to access health insurance solutions and fulfill regulatory requirements. The exchanges will initially be offered to individuals and small employers; after 2017, states have the option to expand operation to include larger employers.

The initial target is for those 24 million uninsured Americans and small employers to use the exchanges, which must offer plans that include a minimum level of coverage established by the federal government. Massachusetts and Utah already have established exchanges; seven states have just been awarded a total of $241 million in grants to develop exchanges. Included in the seven is Massachusetts, which is now expanding its exchange to other states in New England.

Although prior attempts to implement exchanges have met with mixed results, requirements mandated by the new law will be key in avoiding past problems. Nevertheless, key policy issues and considerations will be important for speech-language pathologists and audiologists.

Issues

A report by The Commonwealth Fund identifies several key issues that must be addressed in the establishment of health care exchanges:

Exchanges must be protected against adverse selection. The inclusion of healthy individuals will balance against sick or high-risk individuals who are more expensive to insure.

Exchanges must be of sufficient size to cover widespread participation. A larger exchange will benefit from economies of scale, and available government subsidies will make insurers more willing to take on a larger pool.

Market structure and geographic coverage must be considered. Massachusetts, for example, is using grant money to expand to other states in New England.

Exchanges should offer a range of plans while avoiding complexity. Consumer education is essential to understanding choices and to making selections.

Plans must disclose their terms of coverage. This requirement is a part of the needed consumer education.

Exchanges should aim to foster competition among insurers, focusing on price, value, and quality.

Administrative costs must be held to a minimum.

The creation of the market must be balanced against the regulatory responsibilities.

Exchanges will play an important role in administering subsidies to help low- and middle-income families to afford insurance. Coordination with other public programs is critical; individuals will move among programs and that movement must be seamless.

States are mandated to participate in exchanges, and may choose to operate their own or participate in regional or national exchanges. Should states decline to establish or participate in an exchange, the federal government would operate the exchange for the state.

The health reform law does not state how the exchange is to be governed. The structure must, however, allow exchanges to relate to other state and federal institutions.

Implications for Speech-Language Pathology and Audiology

Exchanges provide a framework for selection and election of health plans, but don't specify the scope and nature of the coverage within each plan that is a part of the exchanges. The exchanges must offer at least one plan within each of two categories:

Gold: provides essential health benefits and pays for 80% of the costs of the health care services used with the health savings account (HSA) current out-of-pocket limits ($5,950 for an individual or $11,900 for a family).

Other benefit categories include bronze (60% of the enrollee's cost); platinum (90% of the enrollee's costs); and catastrophic (available to those up to age 30 or those exempt from the mandate to purchase coverage).

The role of speech-language pathologists and audiologists in the development of health insurance exchanges will vary by state, depending on whether a state allows providers to have a say in the selection of plans and coverage options. Understanding the selection of plans, the inclusion of benefits, and the planned growth of the exchanges in the state—as well as knowing the unique language of the exchange—are the best preparation as exchanges are implemented. SLPs and audiologists need to know what plans are being considered for inclusion in the exchanges and what those plans offer.

Even more important is to make certain that essential health benefits—including habilitative and rehabilitative services—are included. Although "essential health benefits" must be included in coverage, the various levels of plans may cover more or less of the habilitative and rehabilitative services. In addition, understanding key measures in health care reform and the movement toward value-based health care (paying for results rather than treatment) helps audiologists and SLPs advocate for the plans with which they may already have relationships, as the plans choose to become part of exchanges.

In conversations with individuals developing the exchanges, SLPs and audiologists may want to ask them to:

Elaborate on the plans within the levels of coverage.

Identify the plans that include speech and language services.

Clarify policies about hearing tests and hearing aids to determine whether they are included.

Explain provider rates and how they are set.

Identify the quality measures the exchanges are using to evaluate their choice of plans.

Health insurance exchanges are required by the ACA, and states are in various stages of development and implementation. It is best to check with the appropriate state office to determine the status of any state's program. Providers also are encouraged to contact insurance carriers with which they have contracts to verify the scope and coverage of services that will be offered to those who participate with the exchanges.

"Health Care Reform and Speech-Language Pathology Practice," by Becky Sutherland Cornett, The ASHA Leader, Aug. 3, 2010. A good resource for understanding the future direction of health care practice; Cornett provides background on the value-based purchasing initiative and a framework for professional practice.